Hospital Plans - HealthPlus Rules - Terms and Conditions

Transcription

1 Hospital Plans - HealthPlus Rules - Terms and Conditions Applicable to new registrations or renewals on/or after 1st January ) Definitions Accident Accommodation Private accommodation Bodily injury caused solely and directly by external, violent and visible means. Hospital accommodation is defined as follows: A room in a private hospital which has only one bed or a Vhi Healthcare approved room in a public hospital which has only one bed and which is a designated private bed under the Health Services (In-Patient) Regulations, Semi-private accommodation A room in a private hospital which contains not more than five beds or a Vhi Healthcare approved bed in a public hospital which is a designated private bed under the Health Services (In-Patient) Regulations, 1991 and in a room which contains not more than five beds. Semi-private rate The amount which the hospital would have charged if the member had stayed in semi-private accommodation. Benefit(s) The amount we will pay for any claim as set out in the Rules, your Table of Benefits, Schedule of Benefits for Private Hospital Services, the Schedule of Benefits for Professional Fees and the Schedule of Benefits for General Practitioners. Claim When you ask us to pay benefits for a member included on your contract less any excess that may be applicable. Excess An amount that we will deduct from your claim, as set out in your Table of Benefits. Health insurance contract As defined in the Health Insurance Acts. Hospice An independent free-standing in-patient unit providing multi-disciplinary specialist services to the terminally ill under the supervision of a consultant in palliative medicine recognised by Vhi Healthcare. Hospitals The following definitions apply to hospitals: Hospital benefit Benefits payable for in-patient treatment, day-care and side room procedures. Hospital charges Charges for: (i) hospital accommodation; (ii) services provided by a private hospital or clinic (such as hospital technical charges for the use of the operating theatre, radiology and pathology); and (iii) public hospital statutory levies. Non-participating hospital A hospital listed in the Directory of Hospitals (and Treatment Centres) which does not have an agreement with us but which we recognise, so we will pay part of the hospital charges for Vhi Healthcare approved accommodation. Full details of benefits payable are available from any of our offices. Participating hospital Medically appropriate Medical condition Medically necessary Membership Member Student Subscriber/Policyholder Out-patient consultation Patient Day-patient In-patient Out-patient A hospital listed in the Directory of Hospitals (and Treatment Centres) which has an agreement with us on its charges and the services it provides to our members. We will pay the hospital charges for Vhi Healthcare approved accommodation and services if the member is insured under the appropriate level of cover. Means tests or investigations that, in the opinion of our Medical Director, are medically appropriate having regard to best practice. Any disease, illness or injury. Means treatment or a hospital stay which in the opinion of our Medical Director is generally accepted by the medical profession as appropriate with regard to good standards of medical practice and is: (i) consistent with the symptoms or diagnosis and treatment of the injury or illness; (ii) necessary for such a diagnosis or treatment; (iii) not furnished primarily for the convenience of the patient, the doctor or other provider; and (iv) furnished at the most appropriate level which can be safely and effectively provided to the patient. The following definitions apply to members: You and anybody who is named as an insured person on your membership details. A person who is a dependant of the subscriber/policyholder and is of or over the age of 18 years and under 21 years and is receiving full time education. The person with whom we have made the contract. A visit to a consultant in his/her consulting rooms for a consultation about a medical condition. The following definitions apply to patients: Medically necessary treatment received during a hospital stay in a day care bed (but which is not an overnight stay) for an approved psychiatric day care programme or a procedure listed in the surgery and procedure section of the Schedule of Benefits for Professional Fees, other than for a side room procedure. Medically necessary treatment received during a stay in a hospital bed of at least 24 hours. (i) Medically necessary treatment which does not involve in-patient treatment, day care or side room procedures, and (ii) Consultations with complementary and alternative medicine practitioners. 1

2 Plan Practitioner Audiologist Chiropodist/Podiatrist Clinical Psychologist Consultant Any health insurance scheme we provide which covers the cost of treatment in private accommodation or semi-private accommodation. The following practitioners are recognised by Vhi Healthcare: A diagnostic Audiologist who is registered with the Irish Society of Audiology or the Irish Society of Hearing Aid Audiologists. A member of the British Chiropody & Podiatry Association, or the Institute of Chiropodists & Podiatrists (Rep. of Irl.), or the Irish Chiropodists/Podiatrists Organisation Ltd., or the Society of Chiropodists & Podiatrists (Rep. of Irl.). A full member of the Division of Clinical Psychology of the Psychological Society of Ireland. A medical practitioner who has a current full registration with the Irish Medical Council and who: (i) holds a public consultant post in the Republic of Ireland; or (ii) has held a public consultant post in the Republic of Ireland in the past and now practices within the same specialised field; or (iii) holds the necessary qualifications for a public consultant post in the Republic of Ireland together with evidence of appropriate general professional and higher specialist training to a standard required for such a post in the speciality in which he/she intends to work and has been appointed as a consultant to a Vhi Healthcare approved post in a Vhi Healthcare approved private hospital. Non-participating consultant A consultant who does not enter into agreement with us to accept our benefits in full settlement of his/her fees. He/she receives the standard benefit as set out in the Schedule of Benefits for Professional Fees and may or may not charge an additional fee to patients. Participating consultant Dental Practitioner Dietician General Practitioner Midwife Nurse Occupational Therapist Optometrist Physiotherapist Speech Therapist Procedures Day care procedure Fixed Price Procedure Out-patient procedure Side room procedure Specified Orthopaedic and Ophthalmic Procedures Therapeutic Procedure Renewal date Temporary Stay Abroad Treatment Vhi Healthcare Vhi HomeCare Vhi Screening Year You, your A consultant who enters into agreement with us to accept our benefits in full settlement of his/her fees and charges Vhi Healthcare patients accordingly. A dental practitioner with a current full registration with the Irish Dental Council, who holds a primary dental qualification. He/she is community based and provides dental care. A member of the Irish Nutrition & Dietetic Institute. A medical practitioner with a current full registration with the Irish Medical Council, who holds a primary medical qualification. A midwife who is registered on the midwives division of An Bord Altranais register. A nurse registered with An Bord Altranais. A member of the Association of Occupational Therapists of Ireland. An Optometrist with a current full registration with the Opticians Board. A member of the Irish Society of Chartered Physiotherapists. A member of the Irish Association of Speech and Language Therapists. The following definitions apply to procedures: Treatment or investigation which is marked as Day Care in the Schedule of Benefits for Professional Fees and the Schedule of Benefits for Private Hospital Services. Fixed Price Procedure (FPP) is a term Vhi Healthcare use to describe a variety of specified major complex procedures (i.e. cardiac and neurosurgery). Treatment given to an out-patient which is listed in the Schedule of Benefits for Professional Fees or the Schedule of Benefits for General Practitioners. Treatment or investigation which is marked as side-room in the Schedule of Benefits for Private Hospital Services and for which an extended period of recovery is not required. Specified Orthopaedic and Ophthalmic Procedure is a term that Vhi Healthcare uses to describe a list of specified orthopaedic procedures (principally covering hip, knee or shoulder replacements) and ophthalmic procedures (principally covering cataract procedures) carried out in designated private hospitals. A list of these procedures is available from Vhi Healthcare on request. An action or administration of therapeutic agents to produce an effect that is intended to alter or stop a pathologic process. The renewal date shown in your most recent membership details or any anniversary of that date. A stay(s) outside of Ireland for any period up to but not exceeding 180 days in each calendar year. Any medical intervention for which benefits are payable. The Voluntary Health Insurance Board. The provision of acute care in the home which involves: treatment of patients with acute conditions who would otherwise have required treatment in a hospital bed provision of the level and type of services that would normally be provided in a hospital bed provision of those services within the home and provision of an appropriate level of emergency back-up. A specified screening package carried out in a Vhi Screening Centre, as listed in the Vhi Directory of Hospitals (and Treatment Centres). The period of cover shown in your most recent membership details. The subscriber/policyholder. Definitions relating to Complementary and Alternative Medicine - being services not in accordance with the definition of medically necessary. It is advisable to discuss the suitability of a complementary or alternative therapy with a registered medical practitioner prior to commencing treatment. Visits to the following therapists are eligible for benefit: Acupuncturist A member of the Traditional Chinese Medicine Council of Ireland, or a member of the Acupuncture Foundation Ireland, or a member of the British Acupuncture Council, or a member of the Professional Register of Traditional Chinese Medicine. Chiropractor A member of the Chiropractic Association of Ireland or the McTimoney Chiropractic Association of Ireland. Osteopath A member of the Osteopathic Council of Ireland. Physical Therapist A member of the Register of Physical Therapists of Ireland or a member of the Irish Association of Physical Therapists or a member of the Irish Institute of Physical Therapists. Reflexologist A member of the Association of Irish Reflexologists or the Irish Reflexologists Institute or the National Register of Reflexologists. 2

3 2) Contract a) The terms of your contract with us are in the following documents: (i) These Rules and your Table of Benefits; (ii) The Directory of Hospitals (and Treatment Centres); (iii) The Directory of Approved MRI Centres; (iv) The Directory of Convalescent Homes; (v) The Schedule of Benefits for Private Hospital Services; (vi) The Directory of Consultants; (vii) The Schedule of Benefits for Professional Fees; (viii) The Schedule of Benefits for General Practitioners, and any amendment or variation made from time to time as per rule 2(g). b) In the Directory of Consultants, we list the consultants who are participating consultants. c) In the Schedule of Benefits for Private Hospital Services, we set out the benefits we will pay for private hospital services and the rules we will apply to the payment of these benefits. d) In the Schedule of Benefits for Professional Fees, we set out the benefits we will pay to the consultants and general practitioners for each kind of treatment and the rules we will apply to the payment of these benefits. e) In the Schedule of Benefits for General Practitioners, we set out the benefits we will pay to general practitioners for procedures and the rules we will apply to the payment of these benefits. f) In the Directory of Convalescent Homes, we list the convalescent homes which are eligible for benefit. The most up-to-date Directory of Convalescent Homes is available on our website - Copies are available on request. g) We may change these directories and schedules during the year. The most up-to-date Directory of Hospitals (and Treatment Centres) is available on our website - h) We will pay any benefits we are required to pay under the Health Insurance Acts and any regulations thereunder, even if any part of your contract indicates otherwise. This may result in a lower excess being applied to your claim than otherwise indicated in your Table of Benefits. i) Certain procedure codes listed in the Schedule of Benefits for Professional Fees and the Schedule of Benefits for Private Hospital Services have clinical indications and/or conditions of payment and/or payment indicators attached to them. Benefit for these procedure codes is payable only when, in the opinion of our Medical Director, the relevant clinical indications and/or conditions of payment and/or payment indicators have been satisfied in full. j) In the event of a change to the Vhi Healthcare Directory of Hospitals (and Treatment Centres) whereupon (1) a participating hospital or treatment centre becomes a non-participating hospital or treatment centre or (2) the contract between a participating hospital or treatment centre and Vhi Healthcare is terminated for any reason other than the closure of that hospital or treatment centre, Vhi Healthcare will publish a notice in the major national daily newspapers four weeks in advance of such a change taking effect. 3) Joining Vhi Healthcare a) Additional people may be included on your contract at any time. If you apply to include your child on your contract within 13 weeks of his/her birth, we will insure him/her from the date of birth and we will not apply rules 3(c) and 3(d). Subscribers/policyholders who enrol their new born children within 13 weeks of the child s date of birth will not be charged any additional subscription for that child until the first or next renewal date after his/her birth. b) You can only make other changes to your contract at renewal date. c) If a member has an accident after he/she is included, we will pay benefits for the treatment needed. However, for other treatment, we will pay benefits if it is carried out after the member has been insured continuously for a minimum period of time, called a waiting period. The waiting period is as follows: Member s age when he/she is included Waiting period Under weeks 55 to weeks 65 or over 104 weeks Maternity or pregnancy-related conditions 52 weeks d) No benefits are payable for medical conditions the date of onset of which is determined on the basis of medical advice to have been prior to the date the member was included on the contract, unless the member has been insured continuously for a minimum period of time. The minimum period is as follows: Member s age when he/she is included Minimum period Under 55 5 years 55 to 59 7 years 60 or over 10 years When determining whether a medical condition pre-exists membership it is important to note that it is the date of onset of the condition that is considered rather than the date upon which the member becomes aware of the condition, as medical conditions may be present for some time before giving rise to symptoms or being diagnosed. e) If there is a break of more than 13 weeks in a person s health insurance contract with us and another insurer registered under the Health Insurance Acts, 1994 to 2011, the application will be treated as a new application for membership. f) If a person transfers from a health insurance contract with another insurer registered in Ireland under the Health Insurance Acts, 1994 to 2011, benefits will only be payable up to the level of cover offered by that contract. Additional benefits will be subject to rule 4(b). g) If a member has transferred from a health insurance contract with another insurer registered in Ireland under the Health Insurance Acts, 1994 to 2011, the time he/she was insured under the other contract will be offset against the normal joining conditions (waiting period, pre-existing illness and maternity). 3

4 h) The Scheme is intended for people resident in Ireland and only people resident in Ireland are eligible to join the Scheme. Please refer to Rule 7(b). i) You can cancel your health insurance contract within 14 days of the date of issue of the Terms and Conditions of Membership. We will refund the premium you have paid and will recover from you any benefit we have paid. 4) Renewing the contract a) Your contract will last for one year unless we agree to a shorter period. At the renewal date, you can renew your contract by paying the premium we request. The Rules and your Table of Benefits in place at the renewal date will then apply to your contract. b) You can change your level of cover at your renewal date. If you upgrade your level of cover (i.e. subscribe for additional benefits), the payment of additional benefits will be subject to certain waiting periods in accordance with Rule 4c and Rule 4d. c) If you change your level of cover (with the exception of the benefits in Section 9 of your Table of Benefits) and you or any of the members included on the contract receive treatment during the applicable waiting period if the benefit payable for your claim is higher on your new level of cover, we will only pay the benefits which we would have paid if you had not changed your cover until the applicable waiting period has expired. The waiting periods are as follows: Member s age at the time of change Waiting period Under weeks 55 to weeks 65 or over 104 weeks Maternity or pregnancy-related conditions 52 weeks If you have an accident after you change your level of cover we will pay benefits on your new level of cover. d) If you change your level of cover (with the exception of the benefits in Section 9 of your Table of Benefits) and you or any members included on the contract receive treatment for a medical condition which, in the opinion of our Medical Director, you already had on the renewal date on which you changed your level of cover and if the benefit payable for your claim is higher on your new level of cover, we will only pay the benefits which we would have paid if you had not changed your cover until the applicable waiting period has expired. The waiting periods are as follows: Member s age at the time of change Waiting period Under 65 2 years 65 or over 5 years Maternity or pregnancy-related conditions 52 weeks When determining whether a medical condition pre-exists a change in cover it is important to note that it is the date of onset of the condition that is considered rather than the date upon which the member becomes aware of the condition, as medical conditions may be present for some time before giving rise to symptoms or being diagnosed. e) If you change your level of cover at your renewal date and subsequently wish to revert to your previous level of cover, you may do so within 14 days of the date of issue of the amendment notification and we will pay the benefits which we would have paid if you had not changed your level of cover. 5) Subscriptions and Charges a) You must pay your premium when it becomes due for the duration of your contract. The subscriber/policyholder is responsible for ensuring payments are made. In the event that you do not commence payment of your premium in accordance with the payment terms of your contract, we reserve the right to cancel your contract and we will not pay any benefits. In the event of non-payment in accordance with the payment terms of your contract during the course of your contract term, such non-payment will constitute a breach of your contract. In such circumstances we will not pay any benefits for the contract term and we will seek recovery of the losses and expenses incurred by us as a result of your non-payment. These losses and expenses will be calculated as follows: (i) In the event that no claims have been paid, this will amount to the health insurance levy calculated on a pro-rata basis, together with an administration charge of fifty euro; (ii) In the event that claims have been paid, this will amount to the total outstanding premium due to us. b) For members who pay by salary deduction, the translation of annual premia into monthly or weekly instalments may result in the collection of marginally more or less than the annual premium as a result of rounding to the nearest cent. c) Subscribers/policyholders to HealthPlus Plans with dependants who are students (as defined) may apply for a discount on their annual subscription. The student subscription rate will apply from the date of application for new members, and from the next renewal date (following application for the student rate), for existing members. The student rate will automatically revert to the adult rate with effect from the next renewal date after the student s 21st birthday. Charges/Refunds d) If a change to a Customer Account results in a premium refund or shortfall of less than or equal to 10, no refund or charge will be made due to the administration costs involved. 4

5 6) Benefits a) Hospital Benefit Hospital benefit is payable for in-patient treatment in a participating or non-participating hospital listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan, in private and semi-private accommodation. Details of the benefits payable are contained in your Table of Benefits. b) Professional fee benefit We will pay consultants or general practitioners fees for medically necessary treatment which is covered by the Schedules of Benefits (refer 2 (d)) and is carried out in a participating or a non-participating hospital. If a consultant or general practitioner is non-participating, we will pay the standard benefit as set out in the Schedules of Benefits, even if your treatment is provided on an emergency basis and you may have to pay an additional amount yourself. If the treatment is carried out in a hospital listed in the Directory of Hospitals (and Treatment Centres) which is not covered by your plan, benefit for consultant or general practitioner fees will not be payable. However, professional fee benefit as set out in the Schedule of Benefits for Professional Fees is payable for out-patient procedures, with the exception of out-patient radiotherapy. c) Out-patient benefit Out-patient benefit is payable for treatment as specified in Section 9 of your Table of Benefits. d) General conditions We will pay benefits for in-patient and day-patient treatment, side room procedures, out-patient procedures and Vhi HomeCare treatment for a maximum of 180 days per member in any calendar year, less any days treatment within the same calendar year which has been paid under any other health insurance contract (for benefit in respect of psychiatric treatment and addiction treatment, please refer to Rules 6(p) and 6(q)). e) The benefits which we will pay will depend on the terms of your contract on: (i) the first day of a hospital stay or (ii) the date of the treatment if the member is not staying in hospital. f) If the benefits do not cover the full cost of the treatment, the member is responsible for any balance. g) We will pay the actual amount the member is charged or the benefits payable under the contract, whichever is lower. h) If you use hospital accommodation which requires a higher healthcare plan than you hold, the level of benefits payable, if any, will be as outlined in your Table of Benefits. Where a hospital is listed in the Directory of Hospitals (and Treatment Centres) and not covered by your plan, no benefit will be payable. i) Day care procedures Hospital benefit is payable for specified day care procedures carried out in an approved day care facility listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan. If the day care procedures are performed in an in-patient setting (private or semi-private) the approved day care charges only are payable. If it is medically necessary for the member to receive the treatment as an in-patient, we will pay the full benefits for the hospital charges in accordance with the level of cover under your plan. j) Side room procedures Hospital benefit is payable for side room procedures carried out in a Vhi Healthcare approved hospital listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan. If it is medically necessary for the member to receive the treatment as a day-patient or as an in-patient, we will pay the full benefits for the hospital charges in accordance with the level of cover under your plan. k) Fixed price procedures (FPPs) We will provide the benefit set out in Section 1 of your Table of Benefits for Fixed Price Procedures available in the Directory of Hospitals (and Treatment Centres) included in the Fixed Price Procedure Hospital List. Please note that the level of cover may vary depending on the type of Fixed Price Procedure. Some of these procedures when carried out in other hospitals are not called Fixed Price Procedures and in these circumstances benefit is payable in accordance with the benefits associated with your level of cover for these hospitals, as set out in your Table of Benefits, and not as a Fixed Price Procedure. If you are in any doubt about the level of cover payable in respect of any procedure or treatment, we recommend that you contact us prior to admission. l) In-patient MRI scans If the patient, during the course of a medically necessary stay in a participating hospital listed in the Directory of Hospitals (and Treatment Centres) which is covered by your plan and for which hospital benefit is payable, has an eligible MRI scan performed in an approved MRI centre listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan, we will pay the benefit set out in Section 8 of your Table of Benefits. m) Out-patient MRI scans If the patient attends an Approved MRI Centre that is listed in the Directory of Hospitals (and Treatment Centres) as Out-patient MRI Scans - Category 1, Out-patient MRI Scans - Category 2, or Out-patient MRI Scans - Category 3, we will pay the benefits set out in Section 8 of your Table of Benefits for an MRI scan, subject to the following conditions: (i) The member is referred for an MRI scan by a consultant or general practitioner in the Centres listed for cover for consultant or general practitioner referrals or where the member is referred for an MRI scan by a consultant to a Centre which is listed for cover for consultant referrals only; and (ii) The MRI scan is carried out in an approved MRI centre listed in the Directory of Approved MRI Centres; and (iii) The MRI scan is to investigate or rule out certain medical conditions. A list of the approved clinical indications for which benefit is payable appears in the Schedule of Benefits for Professional Fees. In respect of Out-patient MRI Scans - Category 2, the benefit for the consultant s fee is subject to a maximum of the participating benefit listed in the Vhi Healthcare Schedule of Benefits for Professional Fees. If the patient attends, as an out-patient, an Approved MRI Centre that is not listed in the Directory of Approved MRI Centres as Out-patient MRI Scans - Category 1, Out-patient MRI Scans - Category 2, or Out-patient MRI Scans - Category 3, no benefit is payable for either the hospital charge or the consultant s fee. 5

6 6 n) Convalescent Care We will pay the benefits listed in Section 5 of your Table of Benefits towards convalescent care where each of the following is satisfied in full: (i) If the consultant decides and our Medical Director agrees, that it is necessary for medical reasons for a member to receive convalescent care in a Convalescent Home. (ii) If the stay in the Convalescent Home is immediately after a medically necessary stay in hospital, which is eligible for Vhi Healthcare benefit, even if the hospital is not covered by your plan. (iii) If the member occupies single room accommodation in a Convalescent Home listed in Vhi Healthcare s Directory of Convalescent Homes. o) Transport costs We will pay for the cost of an ambulance/intermediary ambulance where each of the following is satisfied in full: (i) If the doctor certifies that it is medically necessary because the member is seriously ill or disabled; (ii) If the ambulance/intermediary ambulance is used: to transfer a member, who is an in-patient of a hospital, between hospitals listed in the Directory of Hospitals (and Treatment Centres) where at least one hospital is covered by the member s plan; or to transfer the member from a hospital covered by your plan and listed in the Directory of Hospitals (and Treatment Centres) to an MRI Centre listed in the Directory of Approved MRI Centres; or to transfer the member to a convalescent home listed in the Directory of Convalescent Homes, if the stay in a convalescent home is approved; or to transfer the member from a hospital covered by your plan and listed in the Directory of Hospitals (and Treatment Centres) to a hospice; (iii) If Vhi Healthcare benefit is payable in respect of treatment received by the member in the hospital, MRI Centre or convalescent home, to or from which the ambulance/intermediary ambulance transported the member; (iv) If the ambulance/intermediary ambulance company is approved by Vhi Healthcare. The payment of ambulance/intermediary ambulance costs does not guarantee the eligibility for benefit of other charges relating to your claim. Where the doctor determines that the most appropriate level of transport required is a taxi, benefit will be payable directly to the hospital from which the patient is transferred subject to criteria (ii) and (iii) above. p) Psychiatric treatment (i) We will only pay for in-patient psychiatric treatment in a psychiatric hospital listed in the Directory of Hospitals (and Treatment Centres) or an approved psychiatric unit of a hospital listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan for the maximum number of days per member in any calendar year listed in Section 3 of your Table of Benefits, less any days treatment within the same calendar year which has been paid under any other health insurance contract; and (ii) We will pay for day care psychiatric treatment for approved day care programmes in St. John of God Hospital, Stillorgan and St. Patrick s Hospital, Dublin. q) Addiction treatment Each member on your policy is entitled to addiction treatment for: (i) Alcoholism and drug abuse subject to a maximum of 91 days benefit (less any days paid for by another Health Insurance Contract) in any five year period. The five year period is calculated as the immediate five years prior to the discharge date of any such claim; and (ii) Pathological gambling subject to the maximum number of days per member in any calendar year listed in Section 3(a) of your Table of Benefits, less any days treatment within the same calendar year which has been paid under any other health insurance contract. r) Breast reduction Benefit for breast reduction is subject to prior approval and payable only if specific criteria, as set out in the Schedule of Benefits, are satisfied in full. s) Dental treatment Many dental procedures eligible for Vhi Healthcare benefits are classified as day care or side room procedures and many must also be authorised by our dental advisors prior to being performed. Your dental practitioner will need to send a Pre-certification Form and radiological evidence to our Claims Department for assessment by our dental advisors. (i) We will not pay benefits for dental/oral-surgical and orthodontic treatment and treatments related to functional disorders of the chewing system, including out-patient consultations, except for those dental/oral-surgical procedures listed in the Schedule of Benefits for Professional Fees and the treatment listed under Section 9 of your Table of Benefits; and (ii) Professional Fee benefit is payable for non-cosmetic osseointegrated mandibular implants only if specific criteria, as set out in the Schedule of Benefits, is satisfied in full. In addition a grant-in-aid of is payable per implant towards the cost of the implant components. t) PET-CT Scans Benefit for PET CT scans is available to members subject to the following criteria: Prior Approval The member is referred for a PET-CT scan by a consultant The PET-CT scan is carried out at Beacon Hospital, Blackrock Clinic, Galway Clinic, Mater Private Hospital, Whitfield Clinic, St James's Hospital, PET-CT Centre, Cork University Hospital or Hermitage Medical Clinic The PET-CT scan is carried out for one of the clinical indications as specified by us to all Consultants. u) Out-patient procedures Vhi Healthcare benefit is payable for out-patient procedures carried out in an approved hospital listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan. Where an out-patient procedure is carried out in a hospital listed in the Directory of Hospitals (and Treatment Centres) which is not covered by your plan, professional fee benefit is payable in accordance with rule 6b. Hospital charges listed within Section 9 of your Table of Benefits may be included under the out-patient scheme and are subject to the out-patient excess. No professional fee or hospital benefit is payable for Out-patient Radiotherapy carried out in a hospital listed in the Directory of Hospitals (and Treatment Centres), which is not covered by your plan. v) Cancer care support benefit We will pay the benefits listed in Section 5 of your Table of Benefits towards the accommodation costs of a member in a hotel, hostel or B&B when a member travels to receive out-patient chemotherapy and/or out-patient radiotherapy treatment in a Vhi Healthcare approved hospital covered by your plan. Only claims accompanied by dated receipts on headed paper will be eligible for benefit.

7 w) Maternity (i) Hospital Charges We will pay the benefits listed in Section 4 of your Table of Benefits towards the cost of hospital charges for normal confinements in a participating or non-participating hospital listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan, in private and semi-private accommodation. If there are significant medical complications arising from the pregnancy or delivery which necessitate a stay in hospital, we will pay the hospital benefits as listed in Section 1 of your Table of Benefits. (ii) Consultants Fees We will pay part of the consultant s delivery fee as listed in the Schedule of Benefits for Professional Fees. The amount we pay will be higher for a caesarean delivery. Benefits in respect of consultants fees are only payable where the delivery takes place in a hospital listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan. (iii) Home Births We will pay a contribution up to the benefit listed in Section 4 of your Table of Benefits for medical expenses incurred for home births and home nursing by a nurse. Note: Contribution to midwife expenses incurred by a member for home birth is only available when the midwife is registered on the midwives division of An Bord Altranais register and where the midwife has medical indemnity insurance. It is the responsibility of the insured member to ensure that the nurse is registered and has indemnity insurance. x) Pre- and post-natal care We will pay the benefit listed in Section 9 of your Table of Benefits towards the cost of pre- and post-natal care provided the person giving the care is a General Practitioner, Consultant or Midwife. y) Consultant consultations We will pay the benefit listed in Section 9 of your Table of Benefits towards the cost of a consultant consultation, excluding maternity and the 1st visit to a Consultant Paediatrician. z) Clinical Psychologist We will pay the benefit listed in Section 9 of your Table of Benefits towards the cost of a Clinical Psychologist. aa) Hearing Test We will pay the benefit listed in Section 9 of your Table of Benefits towards the cost of a hearing test provided the test is carried out by an Audiologist. ab) Accident & Emergency Cover We will pay the benefit listed in Section 9 of your Table of Benefits in respect of the public hospital out-patient levy. ac) Out-patient Mental Health Treatment We will pay the benefit listed in Section 9 of your Table of Benefits towards the cost of a mental health therapy session in an approved Out-patient Mental Health Centre. ad) Vhi Screening We will pay the benefit listed in your Table of Benefits towards the cost of a Vhi screening, in a 24 month period provided Vhi Healthcare determines it to be medically appropriate, subject to it being provided in a Vhi Healthcare Medical Centre, as listed in the Vhi Directory of Hospitals (and Treatment Centres). This 24 month period begins on the date that the screening tests are performed. Members under the age of 18 years at their last renewal are not covered for screening. ae) Vhi HomeCare Benefit Benefit is payable in accordance with agreed charges for treatment of specified conditions provided by Vhi HomeCare subject to satisfaction of all of the following criteria: 1. The referral is from a General Practitioner relating to a patient in their own home or a Nursing Home in the Greater Dublin Area, or 2. The referral is from a Consultant attached to a hospital listed for benefit from one of the following routes: Accident & Emergency Department Hospital in-patient wards Consultants Rooms Please refer to for the most up-to-date details regarding referring hospitals and conditions approved for cover. You may contact us also if you have a question as to whether a condition comes into this category. af) Child home nursing We will pay the benefit listed in Section 5 of your Table of Benefits for the cost of nursing care at home for a member who is under 18 years of age at his/her last renewal date if his/her general practitioner or consultant decides that, for medical reasons, the member needs to receive care following a stay in a hospital of at least 5 days. This nursing care must commence within two weeks of their discharge from hospital and must be completed within six weeks of their discharge. The person giving the care must be a nurse registered with An Bord Altranais. ag) Parent accompanying child We will pay the benefits listed in Section 5 of your Table of Benefits towards the accommodation and travel costs of a parent/guardian accompanying a child (including new born children) for up to 14 days per child per calendar year following a stay in excess of 3 days in hospital, who is under 14 years at their last renewal date, during that child s hospital admission. No benefit is payable for the first 3 days. The benefit is only payable where the child has received medically necessary treatment in Ireland that is eligible for Vhi Healthcare benefit. The claiming member must be a parent/guardian of the child insured with Vhi Healthcare. Accommodation costs are limited to hotel, B&B, hostel and hospital accommodation. Travel costs are limited to public transport, taxi, hackney and car parking costs. Only claims accompanied by dated receipts on headed paper will be eligible for benefit. 7

8 ah) Dexa scans ai) Mammograms aj) Eye testing We will pay the benefit listed in your Table of Benefits towards the cost of a dexa scan, subject to the following criteria: i. The member is referred for a dexa scan by a general practitioner or consultant to an approved dexa scan centre listed in the Directory of Hospitals (and Treatment Centres); and ii. The dexa scan is carried out for one of the clinical indications as specified in the Schedule of Benefits for Medical Screening. We will pay the benefit listed in your Table of Benefits towards the cost of a mammogram, subject to the following criteria: i. The member is referred for a mammogram by a general practitioner or consultant to an approved mammogram centre listed in the Directory of Hospitals (and Treatment Centres); and ii. The mammogram is carried out for one of the clinical indications as specified in the Schedule of Benefits for Medical Screening. We will pay the benefit listed in Section 9 of your Table of Benefits towards the cost of an eye test provided the test is carried out by an Optometrist or by an Ophthalmic Surgeon or Ophthalmic Physician. 7) Cover outside Ireland Treatment outside Ireland a) We will only pay for emergency treatment a member receives outside Ireland if he/she needs such emergency treatment because of an unexpected illness or accident that arises during a temporary stay abroad. We will pay up to the plan amounts outlined in Section 7 of your Table of Benefits, per temporary stay abroad inclusive of all professional fees. You may also claim for expenses listed under Section 9 of your Table of Benefits. All eligible benefits associated with emergency or prior approved treatment abroad will be issued by Vhi Healthcare in euro, with the exchange rate from the European Central Bank being applied to all charges as at the date of the patient s admission/treatment, where applicable. b) Only members resident in Ireland for at least 180 days each calendar year are eligible for cover outside Ireland and/or repatriation in accordance with Rules 7(a), 7(c) & 7(d). Where a member intends to travel abroad for longer than 180 days, Vhi Assist or any other Vhi Healthcare insurance benefit will not be available in respect of medical treatment abroad. c) We will in certain circumstances, subject to prior approval and satisfaction in full of specified criteria, pay benefit if the member travels abroad to get a therapeutic procedure performed, as outlined in section (i) and (ii) below: (i) For therapeutic surgical procedures* that are currently available in Ireland we will pay up to the average benefit that we would have paid in respect of the same surgical procedure, including professional fees, in Ireland for your level of cover up to a maximum of the plan amounts specified in Section 7 of your Table of Benefits. *as per the current Vhi Healthcare Schedule of Benefits for Professional Fees, Surgery and Procedures Section (ii) For a therapeutic procedure that is not available in Ireland we will pay up to the plan amounts specified in Section 7 of your Table of Benefits, unless a reasonable alternative therapeutic procedure is available here in which case the benefit will be as outlined in (i) above. The member will be liable for all costs that arise above the benefit payable, including all travel and accommodation expenses. The benefit will only be paid out once the treatment has been received and the member submits the relevant completed Claim Form with all required documentation. Note: Benefit is not payable for (a) assessments, investigations or diagnostic procedures required in reaching a medical diagnosis or (b) for follow-up assessments, investigations or non-therapeutic procedures required in the ongoing management of the patient. The costs arising for any of these will be eligible for inclusion in accordance with the eligible out-patient expenses listed in Section 9 of your Table of Benefits. Vhi Assist d) Provided that Vhi Assist are contacted immediately by the member, we provide the following additional services to members who require emergency treatment following an unexpected illness or accident while on a temporary stay abroad: i) A direct payment facility in respect of the benefits referred to in paragraph (a) above where the treatment is received as an inpatient or in the A&E / Out-patient Department of a hospital. All other medical expenses can be claimed in accordance with Section 9 of your Table of Benefits. ii) A 24 hour emergency telephone service A service to assist members in replacing written prescriptions Medical Advice and information on your case Maintaining regular contact with the attending medical providers and monitoring of the member s ongoing care where necessary, if he/she is hospitalised Making contact with the member s doctor in Ireland and immediate family, as well as his/her employer if required. iii) Where possible, Vhi Assist can also recommend a local hospital where members will be able to receive appropriate treatment. iv) Repatriation cover is available, if after a member has been treated, the attending doctor advises and our Medical Director agrees that it is necessary for medical reasons to transport him/her back to Ireland for further treatment. This benefit is available only where all arrangements are made under Vhi Assist. v) Repatriation for further medical treatment will also be arranged by Vhi Assist if the patient is deemed stable and fit to fly by their attending doctor and our Medical Director agrees. The use of an air ambulance to repatriate patients will only be considered where it is deemed by the attending doctor and our Medical Director agrees that it is not medically appropriate for the patient to be accommodated on a commercial flight. vi) A companion, who is with the patient when their illness occurs and accompanies them during repatriation, will be covered up to a maximum of 1,000 in additional travel expenses for returning to Ireland themselves. vii) A further 1,000 is available for additional accommodation costs incurred by a companion who is with the member when illness occurs and remains with the member while they are hospitalised, beyond their scheduled return date to Ireland. These expenses (if approved by Vhi Assist) must be paid by the member and claimed from Vhi Healthcare on their return to Ireland. Receipts must be provided in order to support all claims for this benefit and no benefit is available in respect of day-to-day expenses once the member has been discharged from hospital. Such expenses should be claimed under a member s travel insurance. 8

9 9 viii) If a member dies during a temporary stay abroad, Vhi Assist will arrange the return of their remains to Ireland. ix) Where a child/children under 14 years are travelling with a member who requires repatriation, we will arrange and pay necessary additional costs to return the child/children home or continue to their destination specified by the member, up to a total maximum of 1,000 per child. We will also arrange and pay the travel costs of one adult to accompany the child/children up to a maximum of 1,000. (e) If a case is being managed by Vhi Assist, the member must indicate at the outset whether they hold separate travel insurance in respect of their trip abroad. (f) Where you have made contact with Vhi Assist regarding your treatment abroad, the file reference provided to you at that time must be quoted in all subsequent dealings with Vhi Healthcare in relation to your treatment. Recovery (g) We shall be entitled at our own expense to institute any proceedings we consider reasonable in the member s/subscriber s name to recover any payment made under the terms of your cover for treatment outside of Ireland and any amount so recovered shall belong to Vhi Healthcare. You must also notify Vhi Healthcare in writing if you instigate any action against a third party following an accident abroad. Please refer to section 12 of this booklet for further details. Emergency Treatment Abroad Form (h) While Vhi Assist will provide the option of direct payment to medical providers treating members abroad, the providers may not always accept such arrangements and therefore we cannot guarantee direct payment. (i) If direct payment is not accepted, the member should submit their receipts on their return to Ireland to Vhi, together with a completed part 1 & 2 of the Treatment Abroad Form, which is available from any of our offices or at The medical details will be submitted directly to us through Vhi Assist. (j) For cases not managed by Vhi Assist, we will require a fully completed Treatment Abroad Form to be submitted in support of your claim for emergency hospital treatment abroad. The medical information on this claim form must be completed in English. Exclusions (k) Vhi Assist services or any other Vhi Healthcare insurance benefit in respect of treatment abroad, will not be available for any of the following: Injuries caused during mountaineering (above 4000 metres), motor competitions or professional sports Injuries you receive while breaking the law Injuries caused by air travel unless you are a passenger on a licensed aircraft operated by an airline For routine maternity or pregnancy related conditions If the member travels against medical advice If the member travels abroad to get treatment For Convalescence or Rehabilitation services Routine Dental Treatment (Expenses in respect of Emergency Dental treatment can be included in an annual claim under the terms of a member s Out-Patient cover) Repatriation services under Vhi Assist will not be available for any of the following: Illnesses or Accidents arising from drinking alcohol or taking drugs Deliberately injuring yourself Any nervous or psychiatric condition In the case of war, civil disturbance or terrorism, where we do not deem it safe to send our medical repatriation staff into the area where the patient is staying Vhi Assist does not take the place of travel insurance and we recommend that you buy travel insurance before you go abroad. You may wish to consider MultiTrip from Vhi Healthcare. Also, where a member intends to travel abroad for longer than 180 days in any calendar year, we recommend that you buy separate insurance cover for your trip. You may wish to consider Global from Vhi Healthcare. Please see or contact one of our offices for further details of our treatment abroad procedure.